Thursday, January 10, 2008

Dose Dependent

Sometimes I wonder how much free society doctors know about what their patients are doing. Without going into detail about specific patients, I can tell you I see guys coming in to prison on Valium, Xanax, Klonopin and other medications (or claiming to be on them) from their family doctor or their neurologist or their surgeon. They get the meds for chronic pain, back spasms, anxiety, PTSD, sleeplessness and now (the latest trend) restless leg syndrome. Occasionally the meds get prescribed for panic disorder, but I'm amazed that these folks also seem to be able to tolerate daily amounts of cocaine while suffering from panic disorder.

I don't doubt each of these doctors is acting in good faith, with reasonable care and consideration, in the best interest of the patient. I'm sure each doctor has their own particular 'red flags' to watch for which would trigger concern about addiction or abuse. I would be surprised if they all knew about each other.

Good doctors can be deceived and manipulated just like any other human being. Manipulation and deception go hand-in-hand with addiction. (Just look at the number of times people find Shrink Rap by googling 'how to manipulate my psychiatrist' and 'how to get a shrink to prescribe Xanax'!) Sometimes the doctor only finds out about the substance abuse problem after the arrest. I imagine the hard part then is not getting really pissed off at the patient when you find out you've been deceived. Sometimes when I hear free society docs talk about their cases I suspect substance abuse and suggest that perhaps the patient may not be telling the entire story. Those docs get offended. "You just say that because you work with criminals," they say, "My patient isn't a criminal." Well, a lot of addicts have problems without getting caught.

So what can I do about substance abuse in prison? The key element is education. When I have a patient lobbying for benzodiazepines (Xanax, Valium, Klonopin or something like that), I teach them about the effects of substance abuse on mood or other psychiatric disorders. I teach them about the physical effects of controlled substances, the potential for dependence and addiction, and the legal consequences of using illicit drugs. Finally, I encourage abstinence.

To which the patient usually replies: "I know all that, doc. Stop bullshitting me. The only thing that works is Xanax."

At least I try.