In lieu of an abstract, here is a brief excerpt of the content:

  • Anonymous Phone Calls

Jimmy Sutherland is trading his pain pills for junk on the street," an angry female voice says. "Watch out for him. I thought you should know."

Nurse Traver doesn't recognize the voice in the message, and the caller never gives a name. Jimmy Sutherland is a thirty-seven-year-old outpatient who has been coming to the pain clinic about four times a year for the last three years. He suffers from debilitating headaches and continuous pain in his lower right leg, the result of a traumatic injury from a motorcycle accident that occurred years ago. He refers to the pain as his most faithful friend—he says it reminds him he's alive. However, he has also told the staff at the pain clinic that his narcotics prescription keeps his pain in check, allowing him to lead a relatively normal life.

Although Jimmy has conscientiously come to his appointments in the past, Nurse Traver knows that in the nine months leading up to this call, Jimmy has not been in the office. Each time he has canceled an appointment, his excuses have seemed reasonable—family or job commitments that caused a conflict. During this time, he has continued to renew his prescription regularly. However, he hasn't done anything—like request early renewal or replacement prescriptions, or make multiple attempts to fill the same prescription—that would arouse suspicion of a drug problem. Nevertheless, Nurse Traver forwards the message to Jimmy's physician, Dr. Tolland, along with a reminder of the missed appointments.

Dr. Tolland regularly requires patients who demonstrate indications of drug abuse or diversion to sign a narcotics "contract," agreeing to adhere to the prescribed schedule of medications, as well as to submit to random drug screening. But since Jimmy has never exhibited any behavior that would make Dr. Tolland suspect a problem, Dr. Tolland has never applied these conditions to his treatment.

The pain management team agrees that the call might have been made with malicious intent, but they also realize that they have no way to judge the reliability or veracity of the information in the message. How should they respond to this call?

  • Commentary
  • Paul J. Ford (bio)

Clues about the health and welfare of patients permeate the complex puzzle of providing medical care. One should not ignore any potential call for help from a patient or, in this case, on behalf of a patient. Jimmy should be scheduled for an appointment as soon as reasonably possible, first and most importantly because he is overdue to be seen. This is just good practice, no matter how the lapse in visits came to Dr. Tolland's attention, and he should reinforce the need for regular visits to Jimmy.

Dr. Tolland should also tell Jimmy that there are further issues to be discussed at the visit. The call provides a potential clue that Jimmy requires further pain management, or that he has developed a drug addiction that will harm him. And if Jimmy resists meeting in a reasonable amount of time, using the time-limited, nonrenewable nature of the pain prescription as a behavioral lever would be ethically permissible—perhaps even ethically obligatory.

Telling Jimmy of the phone call is best handled face-to-face. A trusting clinical relationship involves full disclosure whenever possible. When meeting with Jimmy in the clinic, there should be no appearance of trickery or obfuscation. Dr. Tolland should tell Jimmy directly of the call, but he should emphasize that Jimmy's health is his concern—even if the accusations are true, the office visit should not be a punitive situation. Dr. Tolland should also have at hand information about available substance abuse treatment resources and programs. He should explain that he is obligated to rule out the possibility of illicit drug use, both for the clinic's records and as a health check for Jimmy. Random surreptitious drug testing should not be performed—this would unfairly change the rules of treatment for Jimmy. Any drug testing should be with Jimmy's knowledge, and if it is performed primarily to ease Dr. Tolland's conscience or to provide some risk management, it should be done at the clinic...


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p. 11
Launched on MUSE
Open Access
Archive Status
Archived 2012
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