I recently heard a story about a patient who was discharged from the practice at which he was being seen. The reason that physician chose not to stop seeing that patient was a urine drug screen that came back positive for cocaine. When the patient was told, he protested, “But it was just the one time!”
Clearly that patient was upset, and obviously it is up to every individual physician and practice to determine what they will and will not tolerate as far as patient conduct is concerned. But I couldn’t stop thinking about this story today as I was seeing my own patients. If that discharged patient didn’t think one cocaine-positive drug screen was grounds for dismissal, what about two? Three? Four? Did he have a number of positive screens that he would accept as an adequate reason to be discharged from the practice? If so, how on earth did he come up with that number? He clearly thought he deserved a second chance, to chance to make up for the positive screen. Of course, from the physician’s point of view, it seems to me that every single drug screen is an individual “chance”, that every patient has dozens of them, and that the kind of positive screen — and the circumstances surrounding it — are just as important as the screen itself. (See last week’s post on urine drug screens for a bit more on this.)
In the field of addiction medicine, all of our philosophy, advertising, and rhetoric are based on the idea of second chances. Getting treatment for addiction is billed as a second chance at life — sometimes in exactly that phrasing, and sometimes with a bit more subtlety. The best treatment programs recognize that people aren’t perfect, that the habits of addiction are deep-seated and hard to resist, and that slip-ups or mistakes don’t disqualify anyone from recovery. So how do we reconcile this culture of forgiveness with the strict rules and regulations that practices find themselves forced to place around addictive medications?
The aim of treatment in my practice is to move patients away from the symptoms of their disease, which can include the behavioral habits of lying, attempting to get more drugs, relapsing, and many others. Having spent years in the field, I’ve gotten pretty good at recognizing these patterns of behavior when I see them. My treatment program is designed to make things like taking cocaine, or selling Suboxone illegally, easy to detect. When I do detect these behaviors, I have to decide the appropriate response. At what point does my treatment stop helping the patient, and just become another tool they can use to feed their addiction? At what point should I dismiss a patient — after one cocaine-positive urine, or three or four?
In real life, of course, I make these decisions on a case-by-case basis, based on the individual patient, their track record, their willingness to be honest and cooperate with me. As a practice based solely around addiction, I actually find myself in the position of being able to be more forgiving than other practices, like pain management or surgical centers, which are designed to manage different aspects of patient care. Non-addiction centers don’t have the resources, personnel, or training to devote to treating what amounts to a second extremely complicated disease alongside whatever condition they were initially treating. This is how a lot of my patients come to me; after crossing one of the strict rules at a non-addiction practice, they look around for anyone willing to give them that second chance and relieve their pain. That’s what my practice is for. But there does come a time when even my patients run out of chances.
If you have any thoughts on the battle between forgiveness and enabling, please tell us in the comments.