Pain Management/Ethics
TL. a thirty-seven year old Hispanic female. is suing her primary care phvsician. a new internist, her dentist and pharmacy A for malpractice, claiming that thev inappropriatelv prescribed/provided narcotic medications and made her "an addict." TL was in good health with no medical problems until four years ago when she was in a serious auto accident and sustained multiple orthopedic, facial and dental injuries. lmmediately following the accident she had several operations for repair of fractures to her iaw and right arm, plus extensive dental surgery for tooth extractions and plastic surgery. Her recovery was relatively uneventfiil and she was able to return to work part time after about six months. However, she continued to have significant back and neck pain and frequent headaches despite no outward evidence of pathology. For the first two and one half years she saw a primary care physician. a surgeon. a chiropractor and her dentist on multiple occasions.
For her pain. she used a variety of non-steroidal anti-inflammatorv drugs (NSAIDs) and acetaminophen with codeine (APAP # 3 tablets). Prescription records showed her intake of APAP #3 averaged about 6-8 tablets per dav during that time. She claimed that the NSAIDs either did not help or made her nauseated. Most of the prescriptions were written by her primary care physician. but both the surgeon and the dentist also wrote various prescriptions for pain relievers and muscle relaxants including Percocet, Vicodin and Valium. She had most of the prescriptions filled at pharmacv A. a large chain. but she also went to two other pharmacies: one a small clinic pharmacv near her dentist and the other a separate location of the same chain as pharmacv A. Because of continued pain, IL started using larger quantities of the analgesics and valium, sometimes as much as 10-12 tablets per day of Percocet. Her primary care physician talked to her on several occasions about needing to cut back on the medicines. but to no avail. TL. her doctor, the doctor's nurse and the pharmacy developed various strategies and contracts to limit the number of tablets to be taken per day and she was limited to receiving onlv a three dav supplv of medicine at one time.
Much of the communication between the pharmacv and the doctor's office was throught the doctor's receptionist and nurse, who often engaged in somewhat critical or cvnical discussions about TL being a "crock". On several occasions. TL arranged for extra tablets when she would be out-of-town or because she lost the tablets. the neighbor's children stole them or she left them at someone else's house. At one point. the primarv care physician sent her to the Universitv pain clinic. but she left the program after two weeks because it was not helping. Finally in disgust. her primany care phvsician told her he could no longer care for her. She saw a new internist for about three months and continued the same pattern of medication need with the new MD. She also got periodic prescriptions for different pain relievers from her dentist and a local emergency room.
Recently, one of TL's friends told her that she was "addicted" to the medications and that she had been mistreated. This led to a lawyer visit and initiation of the legal proceedings stated at the beginning of the case. At about the same time. a new pharmacist at one of the other pharmacies had called the State Board of Pharmacy about the new internists "excessive prescribing" of narcotics for TL. This has prompted an investigation into the doctor.
Social history. TL is functionally a single mother with two children age 14 and 12. She is not divorced, but lives apart from an abusive husband who has a strong history of alcohol misuse. TL has an associate of arts degree from a local community college and works as a clerk at a local convenience store for a little more than minimum wage. She is covered by the State's basic health plan. She is fairly functional despite back and neck pain that she rates as ranging from 6 to 9 on a scale of 10. She denies alcohol use or other illegal substance abuse, but is a heayy smoker. She is currently undergoing treatment in an inpatient detoxification program on her lawver's advice.
