The Sir Lawrence Olivier of Drug Seekers

When I tell medical stories it is always with a couple of factors built in to protect what really has to be doctor patient confidentiality.

I always delay telling a story.  Sometimes for a decade or more.   And I always change some details. So today's story is true in the overall picture but has a bit of necessary camouflage.

Drug seekers are the bane of the Emergency Room.  They make the system work less efficiently for one thing.

If it were simply a matter of wanting narcotics to get high or to sell to like minded folks it would not be such a big deal.  People make bad choices. But in many ways the scamming of the medical system is a cancerous growth.

It increases costs for everyone.  It makes legitimately ill and injured people wait longer to be seen, potentially with harmful results.  It makes ER staff hardened and cynical, potentially less ready to offer pain meds to people in real need.  It increases liability risks....who is really at fault when a frequent flier turns up hypoxic, caked in vomit from a drug overdose.  Well, the person who abused the drugs of course.  But who gets blamed and potentially investigated...

Don't get me wrong.  I give people narcotics.  Plenty of them at times.   Somebody comes in with a dislocated shoulder and my standard line is "You know that stuff about just saying no to drugs? Well....forget that!"  I have even had a few occasions when notorious drug seekers have turned up with a serious injury.  Surprisingly they tend to make bad choices globally and injuries are common. Under those circumstances I bring out the major stuff, even dosing heavier than usual to allow for likely tolerance levels.

But seriously, coming to the ER expecting a shot of narcotics for your chronic back pain, or for the bad tooth that has prompted (true stat) 53 prior visits.....not appropriate.

Most of the time the process of sorting out the legitimate from the bogus is not rocket science. Some show up obviously intoxicated or stoned.  Their stories are knitted together from the faintest gauze and repeat themselves from one visit to another.  And another.  And another.

But among the mostly unimaginative seekers of Percocet and Dilaudid you do on occasion run across a consummate professional.  A true Prince of Players.  I met one a while back....

It was a tranquil morning.  Usually these folks try to turn up when Chaos reigns, figuring that  most docs will just do what they ask to clear a room.  One also suspects that most substance abusers are not early risers.

The story was concerning.  Headache, tingling and weakness, unsteady gait, loss of part of a visual field.  It was close, so very close to making anatomic sense.  And since neurological diseases are notoriously treacherous it had to be taken seriously.

I had been told that he lived in a half way house.  This is a huge red flag, one which is often a deal breaker.  I asked him about that.  He actually teared up.  After a long minute he answered.

"I have post traumatic stress disorder" he said.  He went on to tell me a story of how he had found his teen aged son who had just committed suicide with a shotgun to the head.  It was a heart wrenching tale.  You did not want to look any closer, or to ask much more.  He said it was years ago and that he had begun drinking, but was now sober.

He was patient as I examined him and did not at first ask for anything for the pain.  He was appreciative and actually thanked me for being a good listener.

With this presenting problem you really don't have a lot of options, you have to do a CT or MRI of the head.  How do you know there is not a tumor there?

While waiting for the scan he said the pain was getting a little worse, and could he perhaps have something for it?

Interesting the first dose of pain medication did not have much effect, so he asked for a second.  And then a third.  Always politely of course.

The scan was negative.  It is always good news to not have a brain tumor.  At this point I figured he either had a migraine, or perhaps some sort of conversion reaction giving him neurological symptoms of psychological origins.  Or.....

I called the half way house up.  They were terse and would not say much.  But what they did say spoke volumes.

"There are no narcotics allowed in our facility."

So I had been scammed. A headache, a plausible story.  But the master touch, the thing that caused me to reduce my usual skepticism, was the story of his son's suicide.  What a horrific thing.

All parents live in dread of some things.  The thought that somehow we would miss some crucial hints of depression and that one of our children might commit suicide sits atop our list of ultimate horrors.  And to find the body...

Why even now I find myself sympathizing with the poor man, even though the story may well have been malarkey.

A truly inspired actor knows one thing above all: his audience.  He can sense what words and gestures and themes will resonate strongly.  Maybe the story was even true, it would make the performance more heartfelt.  But could anyone who went through such unspeakable horrors ever bring themselves to speak of them with a total stranger, just for the purpose of scoring some drugs?

Thirty years on into a career of working with people ever day and I still learn new things about them.