Re: Dodging a bullet

Dr Shearer’s editorial (BCMJ; 2001;43[4]:193) immediately grips the reader by describing the anxiety, defensiveness, and anger we feel when the quality of care we provide our patients is challenged by our College. He also expresses a concern I share over what seems to be a growing tendency for people to blame others when calamity strikes rather than take responsibility for their own role in their misfortune.

However, as a medical educator who trains medical students and physicians on the screening, diagnosis, and treatment of their patients’ substance use disorders, I have some concerns about one of the apparent messages of this editorial. It reads as if a physician, unaware of the patient’s addictive disorder, should not face medicolegal liability for prescribing addictive drugs to a substance-dependent patient who either uses them or sells the prescription drugs to finance his or her illicit drug addiction.

Substance dependence is recognized as a medical or psychiatric disorder by courts, health insurers, and medical organizations including the American Psychiatric Association, whose criteria as laid out in the DSM-IV provide the accepted diagnostic criteria for substance use disorders.[1] I am not certain that failure to detect a disorder provides an effective medicolegal defence for prescribing a treatment that exacerbates the disorder and harms the patient. The physician who provides a steady supply of benzodiazepines or opioids is sometimes financing a significant cocaine or heroin habit and adding to the street supply of diverted drugs. MS-Contin, fondly termed peelers on the street, fetches a good price because when the outer waxy coating is peeled off the easily dissolved core can be quickly cooked and injected.

Physicians are expected to screen for substance use disorders. If brief, simple screening questions (CAGE,[2] AUDIT,[3] SCID[4]) were negative in this case, examination of the patient’s forearms and antecubital fossae might have yielded valuable information. Other helpful diagnostic techniques when a patient reports losing her benzodiazepines but not her antidepressants would be to obtain consent and perform a urine drug screen and request a pharmanet printout from either the College or the patient’s pharmacy. British Columbia physicians are advised in the College of Physicians and Surgeons Policy Manual to “avoid if at all possible, the use of benzodiazepines in management of chemically dependent patients."[5] Substance use disorders are found in up to 30% of patients suffering from mood disorders,[6] therefore careful screening for addictions is essential in mood disordered patients. Substance dependence, even in the absence of mood disorders, can mimic depression, anxiety, and even thought disorders. Pharmacological treatment of mood disorders in the patient suffering from untreated substance dependence tends to be both fruitless and dangerous.

Although Dr Shearer’s metaphor was of a bullet dodged, perhaps he might instead revise it to a shot across the bow, indicating that a change in course might be advisable in order to avoid hazardous waters.

—Ray Baker, MD 
Chair, COHP Committee on Addiction Medicine